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What’s in the Article:
- Family Members Role in the Intervention & Assessment Process
- Determining Mental Disorders from Substance or Medication Induced Psychotic Disorder
- Mental Disorder Symptoms often disclosed and observed during Drug & Alcohol Interventions
- Substance Use Can Greatly Impact Mood & Personality
- Mood Disorders Commonly Observed During Interventions and Assessments
- Anxiety Disorders Commonly Observed During Interventions and Assessments
The Diagnostic Statistical Manual, 5th edition (DSM-5) states that a mental disorder is a syndrome characterized by clinically significant disturbances in a person’s emotions, cognitions, or behavior. The diagnosis comes when the symptoms of the disturbances reach a certain level of impairment or distress. There are two things to note with this thought. One, what is that level, and two, drugs and alcohol use can cause similar disturbances with emotions, cognitions, and behavior.
When active substance use coexists with a range of other psychosocial impairments, the clinician should assume that these impairments are related to the client’s substance use until proven otherwise.
Integrated Treatment for Dual Disorders, A guide to effective practice
Mueser, K.T., Noordsy, D.L, Drake, R.E, & Fox, L. 2003
The debate on how to effectively stage a mental health intervention for clients who have a dual diagnosis involving substance use or who have a mental illness absent of substance use continues on with nobody having a guaranteed solution. Up until 1970, clients with mental disorders had virtually no say about their care, and their needs and care were determined by physicians and sometimes the courts.
Today, mental disorder clients have the ability to refuse treatment unless it is determined they present a danger to themselves or others. The real debate is not whether or not an intervention is appropriate as all clients of substance use and mental disorders will eventually face something by way of intervention and consequences. The question is, are coerced or staged interventions effective in cases of substance induced psychosis and in cases of a true mental disorder absent of substance use?
The quick answer is yes and the strategies vary. Many research studies show that when a substance user, mental disorder client, or a dual diagnosis client faces consequences they are much more likely to change direction. The goal is not to actively force their hand, the goal is to offer help and change the things the family can within the environment that keeps them from addressing their problem.
Anytime you coerce someone with a mental disorder into doing something you risk backlash and retaliation. Having an understanding that the person with a substance use disorder, a mental disorder, or both, is free to do as they choose and that the family has that equal freedom to do as they choose. Letting go of the misconception that an intervention is an ultimatum and understanding that it is a mutual acceptance on behalf of the family and the loved one needing help can be a far more effective starting point.
The thought of it being coercion or an ultimatum is all in the presentation and delivery. In other words, forcing someone to do something is much different than giving them an offering of help. If the person wants to destroy their life, sadly, they can make that choice. The difference is, the loved one needing help has the choice to choose help or stay on their current path. The family and others do not have to make it easy for them to stay on the current path. In other words, family enabling and codependency can make the choice for their loved one to continue on a destructive path an easier one.
The biggest difference between substance use interventions and mental health interventions is the approach and goal. Both interventions would benefit from starting with a motivational approach prior to utilizing boundaries and consequences. Substance use or dual diagnosis interventions typically move from motivation to boundaries and consequences much quicker than mental health. Substance use and dual diagnosis interventions often have a goal of quickly entering treatment or face consequences, accountability, and boundaries. When the patient has a mental disorder absent of substance use, the motivational approach may go on much longer with an immediate goal of medication compliance. When the patient is diagnosed with a mental disorder with no substance use history, past or present, it would be wise for families of the patient to utilize a trained mental health professional such as a Psychiatrist or Psy.D. Utilizing coercive approaches in mental disorder interventions with no history of substance use should always be determined by people qualified to do so. Part of our services is to provide an initial assessment and screening to determine if our agency can help. In the event we can not, we may be able to direct you to those that can.
Family Members Role in the Intervention & Assessment Process
Just about every family that inquires about intervention believes the root cause of their loved ones’ problem is a mental disorder. Families often state they believe their loved one is bipolar and depressed and these concerns are the cause of their substance use. Although this could be accurate, it is not up to the family to determine or make a diagnosis. Many families do provide information that confirms mental disorders were diagnosed in the substance user at some point. Families almost always concede that none of the prior diagnoses and medications prescribed have improved their loved one long term nor has it assisted them in becoming clean and sober. They often state the previous approaches addressed the symptoms at the moment and did not address the causes that led to positive change and outcomes.
The more information the interventionist receives from the family, the more accurate the screening and assessment can be. The information received can help the interventionist formulate a temporary treatment plan and strategy that is subject to change based on what the client presents at the intervention. Even though the family will never be able to provide all the details, anything they can provide is often more accurate and honest than what the client or patient can or will provide. Intervention professionals and the treatment team can and will collaborate over all of the information received from both family and client. With the help of others such as doctors, psychiatrists, clinicians, and case managers from the integrated treatment team at the rehabilitation facility, they can start working on putting the puzzle together.
With all that is involved in mental disorder and substance use disorder interventions, the one role the family is incapable of fulfilling is the role of professional. Even in cases where there is a family member who is qualified professionally, they lose that ability to consult and guide when the patient or client is someone they know or with whom they are affected by or emotionally attached. DIY interventions are not possible for mental or substance use disorders. This is not due to a lack of intellect, this is because of the inability to see things from the balcony and have an unbiased perspective. Flooded minds are not as effective as unflooded minds.
Determining Mental Disorders from Substance or Medication Induced Psychotic Disorder
One of the most difficult tasks for clinicians is determining the cause of the mental disorder symptoms. Drugs and alcohol use can greatly increase mental disorder symptoms in clients previously diagnosed with mental disorders. Alcohol and drugs can also create mental disorder symptoms in individuals with no previous mental disorder at all.
Regardless of which one might influence the development of the other, mental and substance use disorders have overlapping symptoms, making diagnosis and treatment planning particularly difficult. https://www.ncbi.nlm.nih.gov/books/NBK424849/
The book is: Facing Addiction in America, The Surgeon General Report on Alcohol, Drugs, and Health
Us Department of Human Services; November 2016
Many clinicians make decisions based on the onset of symptoms. Although this is an important strategy, the question is what about the onset and cause of the symptoms prior to drug and alcohol use? For clients who have been previously diagnosed with a mental disorder prior to using substances to self-medicate, it may be challenging to determine how accurate these diagnoses are.
When substance use causes a change in symptoms the determination of alcohol and drugs causing the change can appear straightforward. The real challenge for clinicians is answering the question as to whether or not there is a true mental health disorder or are the symptoms and behaviors are a direct result of undisclosed trauma or horrification. In some cases, the client’s implicit memory holds the trauma that can not be remembered by the client such as early childhood trauma that occurred before one’s ability to consciously recall the event(s).
Other problematic concerns with mental disorder diagnoses prior to drug or alcohol use are the patient’s accuracy of the information and the one diagnosing the disorder and prescribing the medication.
To complicate matters further, when you have the patient or client providing surface information or omitting information to a professional who is not necessarily well versed to make such a diagnosis, mistakes can and will be made. Many mental disorders are often diagnosed and treated very quickly. Sometimes as quickly as a 30-minute office visit with the patient’s primary care physician.
We are not suggesting the physicians are not qualified medical professionals nor are we suggesting that every diagnosis is wrong. What is being said is there is far more that goes into accurate diagnoses than a short office visit. Mental disorders and dual diagnosis clients using substances would be more inclined to seek out professionals who are qualified and familiar with mental disorders and substance use disorders. Remember, most substance users are self medicating feelings, thoughts, and emotions. It would not be uncommon for mental disorder symptoms to be present in clients with untreated trauma who are acting out to escape the feelings, thoughts, and emotions before they discover drugs and alcohol as the solution.
Mental Disorder Symptoms often disclosed and observed during Drug & Alcohol Interventions
If you were to spend any time at meetings with members of Alcoholics or Narcotics Anonymous, you would see some profound similarities among its members. When one person speaks, the entire room can nod their head, laugh or cry in unison with one another. How is this and what do they all have in common? Listening to any of them tell their story would scream out mental disorder symptoms in their past. Most of them will tell you that they were diagnosed with several disorders they no longer have. Many were diagnosed even before they started using substances. How is it they no longer have these symptoms simply by working a recovery program and by no longer using drugs or alcohol? I don’t think we have ever intervened on an addict or an alcoholic that did not have oppositional defiant disorder symptoms in their childhood followed by antisocial personality disorder symptoms into their adulthood.
Could one not argue that once the substance user crosses over from use and abuse to mental and physical dependency they are now candidates for an impulse control disorder as they now struggle to control their emotions and behaviors while not being able to stop drug or alcohol use in spite of dire consequences while violating the rights of others and breaking rules and law? The question all of these sober individuals have answered is the question that needs to be continuously asked.
Do the behaviors that present as mental disorder symptoms come from acting out as the result of trauma, emotional pain, uncomfortable feelings, or thoughts, or is it a true mental disorder? Weren’t these individuals self medicating to mask and cover up the problem? Is going to the doctor to be prescribed drugs to take away the feelings, thoughts, and emotions, not the same strategy, just a legal one? The point is, it takes a lot of work and professional collaboration along with honesty from the client to get to the root cause of the problem followed by the formulation of an effective solution.
Trained professional interventionists and integrated clinical treatment teams have many challenges in determining the causes and origins of symptoms. Substances used over a long period of time can cause the client to fall into a drug-induced psychosis and present mental disorder symptoms. Some of the most common drug induced psychosis symptoms associated with Substance or Medication Induced Psychotic disorder (SIPD) are anxiety and depression and less frequently, manic episodes. Here are some other substance induced symptoms often disclosed and/or observed during the assessment and intervention process:
- Substance Induced Delirium – Distorted perception and cognitive impairment
- Substance Induced Dementia – Problems with memory and judgment
- Substance Induced Amnestic Disorder – Loss of memory similar to amnesia
- Substance Induced Psychotic Disorder – Removed from reality. Believing things that are not real
- Substance Induced Mood Disorder – Extreme happiness and extreme sadness. Very similar to Bi-Polar symptoms
- Substance Induced Anxiety Disorder – Obsessive Compulsive behavior, worry, panic, and stress
- Hallucination Persisting Perceptual Disorder – Visual impairments and flashbacks (Common with LSD use)
- Substance Induced Sexual Dysfunction Disorder – Depending on drug of choice this can vary from no sexual interest to extreme sexual interest
- Substance Induced Sleep Disorder – This can range from insomnia to sleeping far more than usual or normal depending on the drug of choice
It is important to remember that it is not the job of any interventionist at any time to make a clinical diagnosis. It is equally as important that interventionists are trained professionals that are capable of screening and addressing the client in their current situation and state of mind in a safe and effective way. Anything that they observe is taken into consideration to formulate effective strategies in order to safely deliver the client to the treatment center. Anything they observe or witness can be passed on to the clients treatment team once they arrive. This is why it is so important for the treatment center to have an integrated treatment team, be dual diagnosis, and be ready to address any possible situation that presents itself. Think of the interventionist as the EMT, the treatment center as the hospital, and the interventionist’s family recovery coaching as the ongoing screening, assessment, and physical therapy for the family.
Here is a look at some of the most common substances being used when called to do an intervention and the effects they can have in relation to mental disorder symptoms.
Symptoms related to alcohol use can occur while actively drinking and for a period of time after the alcoholic stops. Other symptoms can occur during the detox period and some withdrawal symptoms of alcohol can be fatal. It is always recommended that someone detoxing or withdrawing from alcohol be medically supervised when doing so. Here are some of the symptoms associated with alcohol consumption that may present as mental disorder symptoms:
- Dysphoria (Unease and dissatisfaction, opposite of Euphoria)
- Euphoria (Extreme Happiness, opposite of Dysphoria)
- Bi-Polar disorder symptoms of extreme highs and lows
- Impulse Control
- Visual Distortions
- Grandiosity (Symptom of Borderline Personality Disorder)
- Medical Symptoms such as sweats, high blood pressure, tremors, nausea, seizures, and vomiting
Cocaine, Crack, & Amphetamines (Crystal Meth, Adderall, etc.)
Stimulants, especially Crystal Methamphetamines pose the biggest challenges for interventionists, clinicians, and Psychiatrists. So many side effects associated with stimulant use present as mental disorder symptoms. Many of the symptoms seem to last much longer after last use than seen in other substances. Almost every family inquiry in regards to a methamphetamine user appears convinced the user needs to be committed and is acting in an overwhelmingly manic state. It is not uncommon for families to report they believe the methamphetamine user is schizophrenic even when there is no past history or current diagnosis of it. Many methamphetamine users are diagnosed as Bi-Polar as a result of the symptoms they present during the roller coaster of use. When they are under the influence they are at an extreme high, if they manage to stop for a short period of time, they are at an extreme low. Without accurate information, it is not a coincidence that many are diagnosed with Bi-Polar. Long-term methamphetamine use can have a permanent effect on the brain that can cause ongoing psychotic symptoms along with problems with memory and concentration.
Other symptoms of stimulant use such as Crystal Meth Amphetamines that present as mental disorder symptoms are:
- Major Depressive Disorder
- Excoriation Disorder (Picking at skin)
- Mania & Hypomania (Milder version of mania)
- Extreme Highs and Lows (Similar to Bi-Polar)
- Mood Swings
- Anhedonia (Loss of pleasure and Inability to be happy even long after use stops)
- Loss of attention and Inability to concentrate (Similar to Attention Deficit Disorder)
- Engagement in high risk and dangerous behavior
It is often said that an opioid dependent person is either high or is sick with little time in between. The withdrawal from a drug is often the opposite of its effect. For stimulants, many people sleep through the detox period. For opiate users, most are violently ill with flu-like symptoms, have great difficulty sleeping, and are highly agitated. One thing to point out is opioids do not necessarily have the same effect on an addict as they do in a person who consumes an opioid as prescribed for its intended medical purpose. For this reason, many family members are convinced their loved one is suffering from a mental health diagnosis rather than the effects of opioids.
This is mostly because the perception of an opioid addict is someone who is always sleeping and nodding off, which can and does occur. For many opioid-dependent clients, in addition to having sleepiness and nodding off while under the influence, when opioids are abused the effect can often act as a stimulant. Many opioid users who are “hooked” present side effects from opioids that cause increased energy, mania, and talk nonstop. They are known to talk in circles jumping from topic to topic and can not sit still. The average person who is not an addict who has been prescribed an opioid for pain management almost never receives the stimulant effect that an addict would receive; they can, and it is rare.
Think about a stimulant given to a child for ADD or ADHD to calm them down. The stimulant has a reverse effect that most people are unaware of; the same opposite effect can happen with opiates. Here are some of the mental disorder symptoms that present in active opioid users, during the detox period from opioids and in some cases for a period of time into sobriety.
- Mania and Hypomania (often during use and after detox)
- Increased energy
- Restless Leg Syndrome (typically during detox)
- Sleep disorder (Insomnia)
- Anhedonia (Loss of pleasure and Inability to be happy even long after use stops)
- Euphoria (Shortly after the physical detox is over and while using)
- Dysphoria (After the Euphoria and the excitement of feeling better has ended)
- Impulse Control Disorder (Prior to Medically Assisted Treatment, most opiate users could not make it through detox without losing control and leaving against medical advice to go and get opioids to feel better).
Substance Use Can Greatly Impact Mood & Personality
Regardless of the substance used, all have the potential to affect mood and personality. The drug of choice is not the reason people seek help. Families and substance users seek help to address the behaviors and the negative consequences that come with the use. The more alcohol or drugs a person uses and the more frequent they use can cause one to experience drug induced psychosis. Even prescribed medications can cause symptoms of drug induced psychosis and have an impact on mood and personality. Drugs that seem much less of a concern than heroin, crystal methamphetamines, alcohol or cocaine, such as nicotine, caffeine, and over the counter medications, can affect personality and mood. Drugs and alcohol affect people period. A diagnosis for any mental disorder becomes less accurate when drug and alcohol use is involved. People use drugs and alcohol to change the way they feel. The question is, can the feelings be treated through evidenced based therapies and self help groups, or do they require medication to address a true underlying mental disorder? Here are some of the disorders and symptoms often presented in substance use disorder clients:
Mood Disorders Commonly Observed During Interventions and Assessments
As clinicians and interventionists, if we had to pick the most commonly diagnosed and misdiagnosed mood disorder in substance use disorder clients it would be Bi-Polar disorder. The symptoms occur before the substance use, during the substance use, and well after the substance use, especially during detox. Drug and alcohol use causes many Bi-Polar Disorder symptoms and acting out trauma early on in life does too. Acting out untreated trauma does not necessarily mean your brain is wired wrong, it means you don’t want to remember or feel the trauma or pain. In order to properly diagnose a substance use disorder client with Bi-Polar disorder, the client would have to be abstinent from substances and be actively working through their issues using evidenced based interventions and therapies.
Only a trained licensed professional can make a Bi-Polar disorder diagnosis in collaboration with the client’s integrated treatment team consisting of doctors, psychiatrists, therapists, case managers, etc. The diagnosis should not come from the family or be based on a previous diagnosis when the client was actively using substances or acting out untreated trauma and negative experiences, feelings, or thoughts.
Major Depressive Disorder
Drugs and alcohol use can cause the substance user to feel depressed. This can occur leading up to the use of alcohol and drugs while using and during times of abstinence and detox. Major Depressive Disorder symptoms are very commonly observed in substance use disorder clients. The question is, what is the cause of the depressive symptoms? Is it from the substances or is it a mental disorder being self-medicated with drugs and alcohol? Even after a period of sobriety or abstinence, as reality of past actions set in, this can cause depressive feelings and this is often referred to as anhedonia.
An assessment for Major Depressive Disorder (MDD) requires one or more Major Depressive Episodes. One of them is that depression is not caused by a medical condition or a substance. In other words, if the client is using substances, then the disorder can not be diagnosed with certainty. The other three criteria are never having had a manic episode, secondly, not caused by a normal grieving process, and lastly, is causing problems with social, employment, and other activities that are important to the person. Even if you checked the latter three boxes, the diagnosis could still not be made with accuracy or certainty while using substances. Substance use also greatly impacts these other three symptoms.
Antisocial Personality Disorder (ASPD)
We have yet to encounter a substance user that did not exhibit multiple symptoms of Antisocial Personality Disorder. Most substance users are not sociopaths which is something often seen in an accurate ASPD diagnosis when there is no history of substance use past or present. Treatment for substance use in and of itself has shown great success in treating ASPD symptoms caused by substance use. Much of the behaviors of ASPD are traumas, experiences, feelings and thoughts developed early on. ASPD is not diagnosed during childhood. Until the client moves into adolescence or adulthood it is diagnosed as Oppositional Defiant Disorder.
The two main features of Antisocial Personality Disorder are extreme disregard for others and their rights and the inability to form healthy close relationships. When you look at those two things, the question becomes how did they develop these thoughts and feelings?
Let’s consider an example of a child who is emotionally neglected or has a father that is not present in his life. The child starts acting out checking off symptom after symptom on the Oppositional Defiant Disorder and Antisocial Personality Disorder checklist. These symptoms could be arising to attract attention from others including his father. If the child grows up believing that if his own father doesn’t love him then how would one expect this child to think anyone else can or will? The child then puts up walls in relationships during adulthood and never gets into a relationship they can’t get out of before they are hurt or rejected. This looks like someone who doesn’t care about others as they use people in relationships. Is this a mental disorder or is it real experienced trauma that requires therapy and healthy building? So now this same person goes down the path of addiction to medicate the hole or void left from the early experiences and while using substances creates a path of destruction in their wake and shows no regard for anyone or anything they hurt. Is this Antisocial Personality Disorder or Substance Induced Psychotic Disorder? In other words, did the early experiences lead to the ODD and ASPD diagnosis that led to the substance use that worsened the symptoms?
The point is, most substance users act out early on then use substances to medicate the feelings or fill the void. Even when the symptoms appear or worsen as the result of substance use they are often present long before whether professionally diagnosed or not. Is it or was it a mental disorder or was the child just running from something they did not want to feel that needs to be addressed? Is calling it a disorder or a chemical imbalance and treating it with medications any more effective than when they were trying to treat it themselves with drugs or alcohol? Is labeling them with a disorder helpful or harmful? Today, professionals almost never use the terms alcoholic or addicts, they say the person has a substance use disorder.
Only a trained licensed professional can make an AntiSocial Personality diagnosis in collaboration with the client’s integrated treatment team consisting of doctors, psychiatrists, therapists, case managers, etc. The diagnosis should not come from the family or be based on a previous diagnosis when the client was actively using substances or acting out untreated trauma and negative experiences, feelings, or thoughts. The more truthful the family and client is, the better the opportunity for an effective solution and accurate diagnosis.
Dependent Personality Disorder
Dependent Personality Disorder is often observed in the substance user and also in the family members of substance users. Symptoms include feelings of helplessness and indecisiveness caused by a lack of self-confidence and fear of making another bad decision. Although there is no clinical diagnosis for Codependency, Dependent Personality Disorder is very similar. The biggest difference is the nature of the relationship. Codependency is towards a particular person such as the primary enabler to the substance user and vice versa. Those with Dependency Personality Disorder act codependent more frequently and with most people they encounter.
Codependent people and those with Dependent Personality Disorder act out in order to feel loved, have a purpose, and to feel needed in the relationship. Codependent and family members with a dependent personality disorder do not address an addiction issue for fear of what will happen to themselves if the substance user gets better. Dependent Personality Disorder or codependency prevents many interventions from getting started. The fear does not come from the worry of the loved one not accepting help. The fear comes from that they will accept help. The codependent or person with a dependent personality disorder needs the other person to care for so they can feel better about themselves. Most family members who fall into this category would argue and retaliate against these comments and these observations are true.
“Codependent people and those with a Dependent Personality Disorder do not see the intervention as a solution. They see the intervention as taking away their codependent solutions that benefit them and not the substance user”.
Substance users are often called people pleasers. They act differently towards just about everyone they meet. They are often nice and thought to be a good person to the outside world. What lies behind this is often selfishness, self-seeking behavior accompanied by manipulation, and the need for external validation. The same substance user is the opposite towards their own family members and will retaliate and punish them, especially if any of them do not give into their demands. The substance user methodically manipulates and focuses on the codependent primary enabler or the family member with dependent personality disorder as they believe the addict or alcoholic is helpless and unable to take care of themselves and they are needed to keep him or her alive. Enabling can create entitlement and dependent personality disorder symptoms in the substance user. The enabler develops dependent personality disorder symptoms and becomes codependent because the enabling is more about fulfilling their own needs than it is the substance users.
Impulse Control Disorder (ICD)
Addicts and alcoholics act out and behave in many ways that would make many questions their mental state. It is not uncommon for a substance user to act out explosively when confronted or challenged about their drug or alcohol use. An impulse control disorder commonly seen in substance users is called an intermittent explosive disorder. Most family members have seen this behavior either when they confront the substance user or the substance user doesn’t get what they want. It is this behavior that often keeps families from doing an intervention and avoiding the therapeutic confrontation that comes with it. The addict and the alcoholic can literally teach their family not to confront them and keep them in fear while they do nothing in order to avoid the substance user’s wrath and retaliation. While the family is paralyzed in fear, the substance user explodes when confronted because of their fears. Anger comes from fear so when a substance user lashes out like this the question is not why are they so angry, the question is, what are they afraid of.
“In our experience, we know that the addict or alcoholic needs the family’s enabling and codependency to stay comfortable just as much as the family needs their loved ones’ addiction to fulfill their codependency needs”.
Over time the family allows these behaviors to become the new normal and then develops maladaptive coping skills around these patterns of behavior. The family then instinctively relies on these coping skills to function and forgets what life used to be like before these patterns developed. By the time a family member realizes what has happened, they have now developed a greater fear of challenging the situation than are keeping the situation the way it is. Family members fall into unhealthy family roles and codependency and they actually start to find comfort in keeping things the way they are to fulfill the unhealthy role they have developed.
Questions such as what will happen to the substance user if the codependent enabler is not there to take care of them or believing they are needed in the relationship often overrides any rationale and reasoning for unhealthy family members. A martyr family member such as a spouse will continue to allow the status quo in order to remain a victim and shoot down any solution of change and the hero will shoot down any solution that isn’t their idea. The addict and alcoholic often do a great job of turning the tables in a way that keeps the family from realizing, remembering, or doing something about the problem as they manipulate with the fear of anger, outbursts, and retaliation.
Another component of ICD is the inability to control impulses. Once a substance user crosses over from abuse to dependency they could develop symptoms of an impulse control disorder. An addict who is dependent can almost never stop themselves from starting and once they start they can not stop without some form of intervention. Very few substance users can put substances down on sheer will power.
The good news is that once the family does an intervention and takes care of themselves the addict or alcoholic often follows and both are able to maintain a strong recovery program. For the substance user, these impulse control issues often subside and the uncontrollable need to use substances in spite of any consequences is greatly reduced. Equally, the family’s instinctive impulses and reactivity to comfort the addict or alcoholic reduces over time provided they are engaged in ongoing recovery and family recovery coaching.
Narcissistic Personality Disorder
So many addicts and alcoholics present narcissistic personality disorder, before, during, and after drug and alcohol consumption. Addiction is driven by behavior and perception, almost all having textbook antisocial personality disorder and narcissistic personality disorder. For those reading this, professionals included, who feel I have lumped all addicts and alcoholics into one category, I have, and for good reason. Go to any alcoholics or narcotics anonymous meeting and listen. Not one person in attendance will disagree with this blanket diagnosis. Listen to any of their stories, early or late recovery, and you will hear the behaviors of almost every symptom on both of the disorders in any one of the members who choose to disclose with complete honesty.
How do so many improve without medication and with evidenced based Cognitive Behavioral Therapy and 12 step facilitation? The only answer that seems plausible is early childhood experiences that molded one’s thinking and perception of themselves and others have been addressed at its root cause. Past experiences and substance use can cause maladaptive behaviors and coping skills that can cause symptoms found in both Narcissistic Personality Disorder and Antisocial Personality Disorder. Both Cognitive Behavioral Therapy and 12 step facilitation, which are both evidence-based treatments, can have a profound impact and change one’s thinking and perception.
Addicts and alcoholics have a sense of entitlement and ongoing enabling does not make this go away. The longer a narcissistic person is enabled, the more entitlement they have. Another trait of alcoholics and addicts is the need for external validation, another symptom of narcissism. Is this a disorder or is the substance user doing anything they can, whether it involves drugs or alcohol or not, to feel better? Do arrogance and lack of empathy describe a cold heartless person or does it describe a person riddled with fear and self-esteem issues who may have experienced a lack of attention as a child and now self medicates with drugs and alcohol?
Is the common trait of sensitivity among alcoholics and addicts a true narcissist who is unable to receive criticism or is it anger based fear when challenged about their alcohol or drug use? Are all these symptoms really a mental disorder or is the person traumatized and utilizing a maladaptive coping and belief system including drugs or alcohol use that can make symptoms worse? Could they not benefit by addressing the experiences that led to the development of narcissism?
Narcissistic Personality Disorder should not be confused when referencing those with Narcissistic Personality who are not using drugs or alcohol. We are simply saying that when drugs or alcohol use is involved, narcissistic personality disorder symptoms are on display. Past experiences can cause one to self medicate with drugs and alcohol because the narcissistic behaviors that are present were most likely used as a coping mechanism prior to the drug and alcohol use. When consulting with family members and the discussion turns towards behaviors it does not take long for them to describe someone with Narcissism even before the substance use. The question is and always will be, is it a true disorder, or are the symptoms due to drug and alcohol used to medicate feelings and beliefs that can be corrected and that can subside when the substance use stops?
Avoidant Personality Disorder
Those diagnosed with Avoidant Personality Disorder have a fear of rejection. They often avoid relationships for fear of being hurt. Both Avoidant Personality Disorder and Narcissistic Personality share this fear yet the fear is handled much differently. Most substance users can relate to pushing people away who love them the most. Many admit that they rarely if ever engaged in relationships that they couldn’t get out of without feeling rejected. People in this category would appear narcissistic as if they did not care about others, yet they are actually the opposite. They care so much about not being hurt themselves that they put up walls to not let anyone in. It is almost to say they suffer from the “it’s not you it’s me syndrome.” In other words, they are not pushing the other person away because they are heartless, they are pushing them away because they do not want their heartbroken and are afraid of being loved.
Narcissistic personality disorder and avoidant personality disorder are very similar. The biggest difference is the person with Avoidant Personality Disorder avoids social interaction. The person with Narcissistic Personality Disorder does not avoid social interaction and is more likely to be outgoing and use people and then reject them before they can be rejected themselves. Both have a fear of being rejected yet the Narcissist takes it to a different level of punishment in hurting others with their ego and arrogance. Avoidant personality disorder has been referred to as covert narcissism.
As with most mental disorders listed here, you would be hard pressed to find a member of Alcoholics Anonymous or Narcotics that could not relate to these feelings and present the symptoms listed in both avoidant personality disorder and narcissistic personality disorder. For example, if you’re a child who grows up with divorced parents, is adopted, had a lack of parental nurturing, had parents who were hard on you, or had one parent non existent, this could affect a child’s psyche. The child would most likely grow up not believing others are capable of loving them if they believe the people who were supposed to love them the most didn’t. They could develop a lack of trust and would question anyone who showed any interest or love towards them.
It would be common for them to build walls to ward off rejection and to not let others in. At times they may even use people and covertly hurt them as they are hurting themselves. Later in life, they may use drugs or alcohol and experience an instant magical connection that fills that void of love they have been longing for. Why would the addict or alcoholic give up this new found comfort so easily when they finally found what they have been searching for their whole life? So the question is, is this a disorder or is this trauma being self-medicated with a substance? It is not an easy task for clinicians to diagnose narcissistic personality disorder or avoidant personality when there is the possibility of these behaviors and symptoms being caused by trauma and amplified by drugs and alcohol.
One last thing to note is we are never to be the barometer or the opinion of others’ trauma. Even if the one reading this disagrees and believes that their child grew up in a loving caring home, that is your opinion and perspective. There are children who grow up in the inner city with a rough childhood and go on to Harvard, become successful, and never once use drugs or alcohol. Across town, the same child who grew up in a wealthy home who could have gone to Harvard never makes it there because he went to jail then rehab instead. The things that happened in childhood were perceived and handled differently in the two examples.
Obsessive Compulsive Personality Disorder (OCPD) and Obsessive Compulsive Disorder (OCD)
Obsessive Compulsive Disorder is actually classified as an anxiety disorder. It is often confused with Obsessive Compulsive Personality Disorder which is, as it says, a personality disorder. Obsessive Compulsive Disorder symptoms come up often during the pre-assessment and family preparation phase of the intervention. Although there is no scientific evidence to support this next comment, in our experience, addicts tend to display much more OCD behavior whereas alcoholics tend to display more OCPD behavior.
Depending on the drug of choice, the symptoms can be much more severe whether it be OCD or OCPD. A true OCD or OCPD is thought to affect parts of the brain that are also greatly affected by drug and alcohol use. As with every other disorder discussed, the question is, is it a true disorder, acting out trauma, or a result of substance use.
Take a child who is physically abused in the home. On the way home from school they avoid walking on cracks on the sidewalk for well over an hour and to the point of obsession while mumbling and beating themselves up mentally if they step on a crack. They do this to ignore and suppress the thoughts of being abused when they get home. Anyone observing that would think there is something severely wrong with the child. Psychiatrists would label them with multiple disorders including Obsessive Compulsive Disorder. Do they have the disorder or are they acting out mentally and presenting OCD symptoms while avoiding the unwanted thoughts of walking through the front door of their home and being physically assaulted?
So now the disorder is misdiagnosed, the trauma is unaddressed, they are prescribed ineffective or inappropriate medications by their family physician and later in life they turn to heroin, meth, or alcohol. So now what is the diagnosis? The OCD symptoms are now worse as a result of the alcohol or drugs used to self-medicate because what was prescribed isn’t working and now they appear severely mentally ill. At this point they are misdiagnosed, wrongly medicated, have unaddressed trauma and they are self medicating with street drugs or alcohol and mixing them with the medications they were prescribed that were not working in the first place
Let’s assume now, the child was being beaten for not being perfect in every aspect of life through the eyes of his father. The OCD is under control and the drugs and alcohol use has been addressed successfully with evidenced based cognitive behavioral therapy and 12 step facilitation. The adult now becomes a perfectionist, a workaholic, has an extreme need for control, is extremely rigid, and does not bend on the protocol in work or personal life. These behaviors would check many boxes on the Obsessive Compulsive Personality Disorder checklist. Do the adults have the disorder or are they still traumatized by their childhood and have not yet become honest with their treatment, sponsor, or therapist?
Another example is an opiate addict who now receives a stimulant effect from opioids. Most people are unaware that opioids can create stimulant effects. Think about adderall, a legal amphetamine. They give this drug to children, a stimulant mind you, to calm them down.
So the heroin addict is cleaning the house obsessively and with perfection while talking to themselves and the whole family tells us they have severe OCD when all along it is the side effects of an opioid creating an effect that most are unaware of. Many opiate addicts we have encountered who receive a stimulant effect check many boxes on the symptom checker of OCD and OCPD while they are under the influence. Many of these symptoms subside when the drug use stops as there is no longer any mania or OCD because the stimulant effects of the opioids are gone.
Anxiety Disorders Commonly Observed During Interventions and Assessments
Panic attacks do not necessarily mean you suffer from a panic disorder. Panic attacks happen and occur at some point in most people. Panic attacks are an abrupt intense fear or discomfort with several somatic symptoms. Somatic delusions mean, in layman’s terms, your mind is stressing far more than the actual physical concern would warrant. In some cases, the physical concern may not even be real.
An example would be a methamphetamine addict who is having panic attacks over thinking they have bugs in their skin or that someone has planted recording devices in their home. A panic disorder would be when you have recurring panic attacks or unexpected panic attacks over the course of a month. At the same time, the client would become concerned about more panic attacks and start changing their life, habits, and routines around the fear of a new panic attack.
Addicts and alcoholics do a great job of giving their families panic attacks. For example, the addict or alcoholic calls the family in absolute distress stating that if you don’t give them $50 they are going to be kidnapped or killed by their drug dealer. The family has an absolute panic attack as they react to the manipulation and hand over $50 to make the panic go away. So if the addict does this every day for a month (to qualify for a disorder diagnosis), does the family member have a panic disorder, or do they need to learn how to stop reacting?
Many substance users can certainly fall under a panic disorder diagnosis based on a symptom checker. If an addict or alcoholic has a classical conditioning fear of police because of several arrests and incarcerations they may develop a panic disorder because every time they see law enforcement they have a panic attack caused by operant conditioning.
It is like a bee sting. If you are attacked by a swarm of bees, you may have a classical conditioning fear of bees. Every time you see a swarm of bees or even a single bee you may have a panic attack because operant conditioning has trained you to be fearful of every bee. If it is summertime and you see a bee every day then the DSM 5 may qualify you for a panic disorder.
The question is, are these panic attacks caused by the lifestyle choices of the addiction or are they a true panic disorder that is being self medicated by drugs and alcohol? Even if the symptoms were present, such as a bee attack long before drugs and alcohol were introduced, is it a disorder of the brain or can it be corrected with evidence based therapies instead of medications to reduce anxiety and panic?
We often hear of fear, anxiety, and panic disorder when there is sex abuse at an early age. If a person is sexually molested at an early age they may be triggered every time they see someone that reminds them of the person who committed the act. It is very important for the family and the substance user to disclose any such information to ensure the client needs are met such as an appropriate pairing with the most effective therapist they may not trigger them.
Generalized Anxiety Disorder
Generalized Anxiety Disorder requires anxiety or worry that is excessive, happens often, has several issues that you worry about and lasts for at least 6 months. In addition, the anxiety has to be related to at least three of the following symptoms. Restlessness, fatigue easily, concentration problems, irritability, problems with sleep, and tension in the muscles. What is interesting is if you ask any member of Alcoholics Anonymous or Narcotics Anonymous how they felt while using drugs or alcohol and during the time shortly into sobriety they will almost all give you three symptoms of Restless, Irritable, and Discontent. We are not saying that everyone with anxiety, panic, fear or worry is an alcoholic or addict nor are we saying they are a candidate for AA or NA. What we are saying is, that anxiety comes from somewhere and many evidenced based treatments such as Cognitive Behavioral Therapy and 12 Step Facilitation greatly reduce anxiety, worry, panic, and fear.
What if you are an addict or an alcoholic who committed a crime and are in fear, worry or panic of prosecution every day having to look over your shoulder for 6 months? Would you qualify for a panic disorder or should you turn yourself in and take the steps towards sobriety to remove the anxiety? What we are trying to relay is that when drugs or alcohol use is present, symptoms of anxiety disorders are too. We in no way, shape or form, discount anxiety disorders, especially in clients who have no drug or alcohol use history.
Those symptoms and diagnoses can be much more accurate when you are looking at the client’s absence of chemical reasons that cause these symptoms. Far too often families and substance users rely heavily on mental disorders as the cause of their substance use disorder, and in some cases that may be true. Until the substance user is detoxified and under the care of an integrated treatment team an accurate diagnosis is difficult for any clinician, doctor, or psychiatrist to make. The diagnosis of any disorder should never be made by the substance user, their family, or an unlicensed or unqualified person.
Integrated Dual Diagnosis Treatment for Mental Health & Substance Use Interventions
Most clients with substance use disorder present with mental disorder symptoms. There is no way for anyone in the family to know exactly what the problem is. This task is reserved for professionals. There are three different types of treatment for dual diagnosis. These include sequential, parallel, and integrated. Sequential treatment means you treat one problem at a time and at different agencies. So if the client presents with a substance use disorder and a mental disorder they will see an entirely different treatment team and at a different agency after each diagnosis is addressed. The second diagnosis is not addressed until the first one is completed. Parallel treatment means the client will have the dual diagnosis treated simultaneously, it will just be with a different agency and with different providers. An integrated treatment team will address all diagnoses at one agency with the treatment team working together. This approach is often the most effective in dual diagnosis clients.
Know When To Seek Intervention for Mental & Substance Use Disorder
Inquiries for interventions are most often about the behaviors over substance use and the behaviors over the mental disorder diagnosis. Although most families call in regards to the addiction or mental health concerns, they quickly realize they are calling about the destruction to both the family and the intended patient (IP). Regardless of whether or not it’s a mental health or substance use primary diagnosis, if someone is in need of help, please contact the professionals. The diagnosis of what is wrong is reserved for the professionals and not the family of the client or the client themselves. Although family history and insight is extremely important, it requires honesty from the client along with a professional experienced and educated treatment team. One of the 12 core functions of a counselor is patient screening. By contacting an intervention coordinator at Family First Intervention, we are able to hear about your situation and concerns and either move forward with an intervention or refer you to a more appropriate agency or treatment team. The first step for the family is making the call and doing a phone assessment and screening to determine if your case warrants an intervention through our agency or another.